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CalREDIE Syphilis-SpecificTabs and Forms:

Highlights & Helpful Hints

Revised 11/1/2017

Questions: STDCalREDIE@cdph.ca.gov

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Patient tab Never close as Syphilis:

Initial Report (refer the “Syphilis Case Closure: Acceptable Process and Resolution Statuses” STD resource document)

Should match the dispo’d disease found on the HDFU, regardless of whether it started as an Initial Report or Contact The address should reflect where the

patient resided when diagnosed, not where they may have moved to since then

Do not close female syphilis incidents (of childbearing age) with pregnancy status as unknown

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Patient tab continued

MultipleIdentities(e.g., aka, alias)

MultipleAddresses(e.g., home, school)

For females, document pregnancy status on the proper incident(see maternal incidents processing flowchart)

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Patient tab – Multiple Identities

Only the “Primary Identity” appears in the Person Search screen, however if you click on “Additional Demographics” you will find Abigail when searching on Abby.

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Patient tab – Multiple Addresses

Only the “Primary Address” appears in the Person Search screen, however if you click on “Additional Demographics” you will find 1616 Capitol Ave when searching on 34Sacramento. Multiple Addresses is where you can enter other known addresses for the patient.

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Clinical Info tab (excl. CS)

Do not change what the provider reported as the clinical diagnosis; it does not have to match the final case diagnosis.

Document all symptoms observed by the provider, including Neuro, Ocular, and Otic

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Clinical Info tab (excl. CS) continued

Document all treatments & dates associated with current infection

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Laboratory Info tab

Negative results are not reported via ELR; they can be entered in the Syphilis Laboratory Results Summary section

Do not re-enter ELR results in the Summary section

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HDFU tab – Investigation sectionsINVESTIGATION INITIATEDComplete this form for ALL syphilis-related incidents: Positive tests (referral basis PT,

O3) Contacts/clusters (referral basis

P1-P3, A1-A3, S1-S3, O1-O2) Congenital syphilis (referral basis

CS)

INVESTIGATION OUTCOMES Disease being investigated

should be:• 700 for positive tests • Original patient’s diagnosis

for contacts/clusters • Mom’s diagnosis for CS

Do not use HIV dispositions for syphilis or vice-versa

Do not disposition CS as “L” Diagnosis should match the

Disease on the Patient tab

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HDFU tab – HIV section

Complete the HIV data for ALL syphilis (& CGSS) related incidents

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Contacts tab

Always use the “Link Patient” button to search for a person.

In the above example, an incident was created from the contact widget for the baby only because a CalREDIE search revealed that an incident did notalready exist for the baby.

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Contacts tab continued

Always create a contact incident for non-CS contacts/clusters, even if a positive test incident is already being investigated. If a positive test incident is already being investigated, then the contact incident can be closed as previously reported with the condition the same as on the contact’s positive test incident. In addition, the HDFU should still be completed, regardless of the existence of a positive test incident.This is necessary for partner service performance measures.

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Case Investigation tab

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Case Investigation tabCase Information & Reporting Source

CASE INFORMATION Ensure the proper jurisdiction has been

selected• Should not be Los Angeles or San Francisco

(both are non-participating jurisdictions) –refer to the CalREDIE Reference Guide (pages 59-60)

• Should also not be Out of State – refer to the CalREDIE Reference Guide (page 58)

Assign to the appropriate investigator

REPORTING SOURCE Select the provider who ordered the test

• ELR data may initially populate this field, but you should revise it

Select the lab name if not already populated with the ELR lab’s name

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Case Investigation tab – Dates Date of Onset

• STDCB not really concerned about an entry in this field Lab Specimen Collection Date

• Should be manually entered if incident based on a paper lab report• If ELR, will be auto-populated, but occasionally may need manual entry

due to bad format in ELR message Lab Specimen Result Date

• Should be manually entered if incident based on a paper lab report• If ELR, will be auto-populated, but occasionally may need manual entry

due to bad format in ELR message Date of Diagnosis

• May be auto-populated from a web-based provider report• Should be the date the doctor diagnosed or if not provided, then date

of treatment Date of Death

• Should always be left blank for syphilitic stillbirths Date Received

• Is auto-populated with the date the incident was created, however can be edited to reflect an actual receipt date

Date Created• Is auto-populated with the date the incident was created

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Case Investigation tab – Statuses Process Status (Typical workflow)

• Entered• Under Investigation • In LHD Review• Closed by LHD• Closed by State (CS and late with clinical manifestations)• Notes: Out of State will trigger an alert to STDCB ICCR; Jurisdiction Transfer

requires direct contact (phone/email with the other LHJ) Reported by

• Web Report should be checked if provider reported via CMR or provider portal

• Lab Report should be checked if ELR or paper lab received Import Status

• Optional: May be used to indicate if the incident was indigenous or imported from another area (LHJ, state, country)

Resolution Status• Case countable values are Confirmed, Probable, Suspect,

Unknown and missing (last 2 are typically data entry errors)• Refer to the “Syphilis Case Closure: Acceptable Process and

Resolution Statuses” STD resource document Final Disposition

• Optional: May be used to document Administrative Closure, Follow-up Completed, Lost to Follow-up, No Follow-up Needed, and Record Search Closure

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Case Investigation tab – Notes

All notes are user, date and time stamped when entered, and are not editable. There is a total size limit for this field of 7,000 characters.

Include information related to medical observations, plans of action, including planned follow-up serologies (if any). If this information is captured in a notes section elsewhere in the incident (e.g., IR form Investigation Plans & Supervisory Review), then indicate that in the Notes/Remarks section on the Case Investigation tab.

Document incident numbers of any other related cases to mother, father, or baby’s cases as reference.

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Electronic Filing Cabinet (EFC)

Medical chart notes, syphilis summary report, and various other documents can be scanned and placed in the EFC. • For CS cases, be sure to upload a copy of the mother’s syphilis summary report• The Syphilis Interview Record is also available for completion through the EFC

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Syphilis Interview Record (EFC form)

Interview record ID is the CalREDIE Incident ID padded with leading zeros to make it 8 characters

IR is required for all early syphilis cases & pregnant late syphilis cases, even if not interviewed (form includes fields to indicate if not interviewed and why)

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Syphilis Interview Record continued

If mom had no labs done during pregnancy, then “Pregnant” on the Patient tab should be NO, and Other pregnancy in last 12 months on the IR should be YES. The minimal information on the IR must be completed, even if the mom was not interviewed.

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Syphilis Interview RecordRequired Entry

Minimal fields required to save the form• Stage of Syphilis: Neurosyphilis• Additional Address Details: Residence type• Additional Demographics: Gender at birth• Reporting of Case: Date of 1st specimen collection, Date lab report received,

Date Provider first reported/contacted, Reported via, Date case was first assigned & DIS

• Basis for Early Stage: Basis & If history in past 12 months Additional fields are required once a data closed is entered on the IR form OK to leave unasked fields blank if not required

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Patient tab – Baby’s incident

Correct baby’s name to his/her actual name before incident is Closed by LHD If twin births (or more), be sure to enter a unique name for each infant; if actual

names are not yet known, then enter something like Baby Girl 1 and Baby Girl 2, or Baby Girl and Baby Boy

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CS Case Report tabTo expedite case review/closure, the entire form should

be completed, even if BFP/not a case

Enter the “Mother’s CalREDIE Incident ID#” exactly as it appears in CalREDIE • Should be the mother’s incident associated

with this pregnancy, not one from a year or more prior

Do not enter• Multiple CalREDIE Incident IDs • Other characters like pound signs, commas, or

semicolons• Names• Leading zeros

“Report date to health department” should not be prior to the baby/child’s DOB

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CS Case Report tab continued

Only enter non-treponemal test dates and results from during the pregnancy and/or delivery

Dates should be in descending order, i.e., most recent first At minimum, be sure to document the most recent test and the first

(oldest) test from during the pregnancy and/or delivery• If only one test, then you need to enter it only once

The most recent test should always be recorded in the “a. Date” section

If more than four non-treponemal tests were done during pregnancy:

• Enter the first (oldest) test in the “d. Date” section• Enter the next test with a titer drop in the “c. Date” section• Enter the test just prior to the most recent test in the “b. Date”

section

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CS Case Report tab continued

Enter the mother’s first treponemal result and date from during the pregnancy (or delivery if none during pregnancy)

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CS Case Report tab continued

“Date of death” should be blank for syphilitic stillbirths

Birthweight should always be obtainable from the delivery hospital; enter whole numbers only, i.e., 3285 (not 3,285, not 3285g, not 3.285, not 3.285 kg)

Enter numbers only for gestational age, i.e., 38 (not 38w) or 38.57 (not 38 4/7, not 38w 4d). Can also just enter 38 instead of 38.57.

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CS Case Report tab continued

Dropdown values for questions 28a and 29a have been revised to clarify that “No” is for capturing tested with a negative result:Prior Values Revised ValuesYes, serum Yes, serum reactiveYes, cord blood only Yes, cord blood reactiveNo No, result non-reactiveNo test Not testedUnknown Unknown

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CS Case Report tab continued

Complete the CS case classification utilizing the CS algorithm. Also update the Resolution Status on the Case Investigation tab appropriately:CS Classification Resolution StatusNot a case Not A CaseConfirmed case ConfirmedSyphilitic stillbirth ProbableProbable case Probable

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MergesPatient

User marks patients for merge• Full instructions available on the CalREDIE Help page under “User Guides &

Reference Materials” User completes the Patient Merge Request Form and emails it to CalREDIE Help

• Form available on the CalREDIE Help page under “Additional Forms & Resources” CalREDIE Help completes the requested merge CalREDIE Help sends a confirmation to the user

Incident User marks incidents for merge (must be of the exact same condition)

• Full instructions available in the Reference Guide on the CalREDIE Help page under “User Guides & Reference Materials”

User completes the incident merge

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Out of State RequestsSyphilis Record Searches

Requests for Out of State record searches should be faxed (916-440-5348) or secure emailed (stdsurv@cdph.ca.gov) Must specify state(s) to be searched (no nationwide registry) Instructions are available on the STD CalREDIE Resources FAQs page under

Frequently Asked Questions (see #8) Responses may take anywhere from a few hours to a few weeks, depending on

the state and their available resources

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Out of State Requests continuedInitiating Contacts

Requests to initiate Out of State contacts may be done through the CalREDIE incident that has been created for the contact Patient tab – complete as much demographic information as available HDFU tab - complete the INVESTIGATION INITIATED and REFERRAL TO HEALTH

DEPARTMENT sections, as well as the “Disease being investigated” in the INVESTIGATION OUTCOMES section (use the Add button if a contact to more than one disease)

Case Investigation tab • Keep your jurisdiction as the Primary Jurisdiction – this allows you to retain edit

rights which are needed for documenting partner outcomes once received back from out of state

• Set the Secondary Jurisdiction to “Out of State” (optional)• Keep yourself as the Investigator• Set the Process Status to “Out of State” – this will trigger an alert to the STDCB ICCR

desk• Set the Resolution Status to “Out of State”• Add any relevant notes to the Notes/Remarks section that might help in locating

the contact

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Out of State Requests continuedInitiating Contacts continued

Upload all relevant documents into the EFC Send an email with the Incident number and City/State to the STDCB ICCR desk

• Do not include any personal identifiers in this email STDCB ICCR desk will initiate the contact to the other state STDCB ICCR desk will update the incident once disposition information is

received back from the other state STDCB ICCR desk will then email the requesting investigator

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Jurisdiction Transfers

To a CalREDIE Participating Jurisdiction Upload all relevant documents into the EFC Select the proper jurisdiction on the Case Investigation tab (your jurisdiction will

become the secondary jurisdiction) Set Process Status to “Jurisdiction Transfer” Add any notes you might have to the Notes/Remarks field Click on Submit Contact the jurisdiction that the incident was transferred to via fax, phone or

email, using the Incident ID to reference the incident

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Jurisdiction Transfers continuedLos Angeles or San Francisco Morbidity

Keep your jurisdiction as the Primary Jurisdiction• This allows you to retain edit rights

Set the Secondary Jurisdiction to Los Angeles (or San Francisco) Set the Resolution Status to “NPJ Incident” Fax and/or mail lab/CMR/notes to Los Angeles (or San Francisco) Once done with the incident, revise Process Status to “Closed by LHD”

Contacts in Los Angeles or San Francisco Keep your jurisdiction as the Primary Jurisdiction Set the Secondary Jurisdiction to Los Angeles (or San Francisco) Set the Resolution Status to “NPJ Incident” Initiate contact via fax, phone or mail to Los Angeles (or San Francisco) Upon receipt of partner investigation outcome from Los Angeles (or

San Francisco) :• Update the Patient, Clinical Info, and HDFU tabs

Once done with the incident, revise Process Status to “Closed by LHD”

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Jurisdiction Transfers continued

Out of State Morbidity Upload all relevant documents into the EFC Keep your jurisdiction as the Primary Jurisdiction Set the Secondary Jurisdiction to “Out of State” (optional) Set the Process Status to “Out of State”

• This will trigger an alert to the STDCB ICCR desk Set the Resolution Status to “Out of State” STDCB ICCR desk will print & mail all relevant documents to the other state STDCB ICCR desk will then close the incident

STD CalREDIE Resourceshttps://www.cdph.ca.gov/Programs/CID/DCDC/Pages/STD-CalREDIE-Resources.aspx

CalREDIE Helphttps://www.cdph.ca.gov/Programs/CID/DCDC/Pages/CalREDIE-HELP.aspx

(866) 866-1428CalREDIEHelp@cdph.ca.gov

Contact CalREDIE for the password